Arterial stiffness of the aorta and iliofemoral artery and their responses to nitroglycerin administration in myocardial infarction-prone Watanabe heritable hyperlipidemic rabbits.

OBJECTIVES: The role of hypercholesterolemia in arterial stiffness, which usually reflects the progression of atherosclerosis has not been fully investigated. To clarify the meaning of arterial stiffness in hypercholesterolemia, we evaluated arterial stiffness in myocardial infarction-prone Watanabe heritable hyperlipidemic (WHHLMI) rabbits by using new arterial stiffness indices of the aorta and common iliac to femoral artery. The new arterial stiffness indices of both arteries were determined by the application of the theory of cardio-ankle vascular index (CAVI) to the aorta (aBeta) and ilio-femoral artery (ifBeta). Furthermore, the responses of both indices to nitroglycerin (NTG) administration were compared between WHHHMI and normal rabbits. DESIGN AND METHODS: aBeta and ifBeta of WHHLMI and normal rabbits were measured under anesthesia. Pulse wave velocity in the whole aorta (aPWV) and ilio-femoral artery (ifPWV), blood pressure, and other parameters were measured before and after administration of NTG (50-120 µg/kg/min) every 1 for 5 min. RESULTS: Atherosclerotic lesions were observed in the aorta, but a little in the ilio-femoral artery in WHHLMI rabbits. Compared with normal rabbits, aBeta was significantly higher, but ifBeta was lower in WHHLMI rabbits. When NTG was administered, ifBeta decreased significantly in both groups; however, aBeta increased in normal rabbits, but remained unchanged in WHHIMI rabbits. CONCLUSION: These findings suggested that hereditary hypercholesterolemia in rabbits did not uniformly enhance arterial stiffness in elastic artery and muscular artery. The responses to NTG were also different between two arteries. The mechanism of these different responses needs further studies.

Transbrachial Mechanical Thrombectomy for Acute Ischemic Stroke in Marfan's Syndrome: A Case Report.

Objective: Marfan's syndrome (MFS) is a systemic connective tissue disorder with autosomal dominant inheritance. Cardiovascular complications of MFS such as aortic root or valve disease and aortic aneurysm or dissection are potential cause of access route problems of mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Here, we report a case of a patient with MFS who underwent MT for AIS. Case Presentation: A 58-year-old woman with MFS presented with a sudden onset of consciousness disturbance and right hemiparesis, and was referred to our hospital. After the infusion of tissue plasminogen activator, CTA showed a type III arch in the aortic arch and severe tortuosity of the thoracoabdominal aorta; thus, angiography was performed using the transbrachial approach. Left common carotid angiogram showed complete recanalization of the left middle cerebral artery. On the sixth day, the patient presented a sudden consciousness disturbance and left hemiparesis. MRA showed right internal carotid artery occlusion. MT was performed by the transbrachial approach, and complete recanalization was achieved on the first pass. Conclusion: MT via the transbrachial approach is a treatment option that should be considered, especially in MFS, where the transfemoral approach is difficult due to anatomical problems.

Endovascular Mechanical Thrombectomy with a Large-Bore Aspiration Catheter and Stent Retriever for Cerebral Venous Sinus Thrombosis in Pregnancy: A Case Report.

Objective: A case of cerebral venous sinus thrombosis (CVST) during pregnancy effectively recanalized by endovascular mechanical thrombectomy with the combined use of an aspiration catheter and a stent retriever is reported. Case Presentation: A 27-year-old woman at eight weeks' gestation developed sudden onset of right hemiparalysis and seizures and was referred to our hospital. Her National Institutes of Health Stroke Scale score on admission was 23. On MRI, diffusion-weighted imaging showed a hyperintensity area in the left frontal lobe, and T2* imaging showed hemorrhagic infarction in the same area. MR venography showed obstruction of the anterior two-thirds of the superior sagittal sinus (SSS). Anticoagulant therapy with heparin was started, but since the venous return was expected to be severely impaired, mechanical thrombectomy by endovascular surgery was selected, hoping to resolve symptoms early. Using a large-bore aspiration catheter in combination with a stent retriever, it was possible to safely guide the aspiration catheter into the anterior half of the SSS. The use of a large-bore aspiration catheter enabled retrieval of a large amount of thrombus in a short time, and complete recanalization was achieved. The patient's hemiplegia and aphasia improved significantly within a week after the procedure, and she was discharged without sequelae. Conclusion: Mechanical endovascular therapy of CVST performed with a combination of a large-bore aspiration catheter and a stent retriever should be considered particularly for patients with severe neurological symptoms or intracranial hemorrhage and for those who do not respond to anticoagulation therapy.

A case of intracranial myxoid mesenchymal tumor with EWSR1:CREM fusion in an adult female: Extensive immunohistochemical evaluation.

Intracranial myxoid mesenchymal tumor (IMMT) is a recently described, extremely rare group of neoplasms characterized by fusions between the female-expressed transcript (FET) family genes and the cAMP response element-binding protein (CREB) family genes. Controversy persists regarding whether the tumor is a myxoid variant of angiomatoid fibrous histiocytoma or a completely distinct clinicopathological entity. Here, we report a case of IMMT arising in the posterior fossa in a 65-year-old woman with a history of breast cancer. We performed total removal of the tumor, which histologically demonstrated features characteristic of IMMT but also bore a partial resemblance to conventional angiomatoid fibrous histiocytoma. Immunohistochemically, tumor cells were diffusely positive for desmin, vimentin, cluster of differentiation (CD) 99 (CD99), glucose transporter-1, and cytokeratin (CK) 8/18 (CK8/18), and focally positive for CK7, epithelial membrane antigen, mucin 4, anaplastic lymphoma kinase, calponin, and CD68. Molecular genetic analysis revealed a fusion between the Ewing sarcoma breakpoint region 1 (EWSR1) gene (EWSR1) and the cAMP-responsive element modulator (CREM) gene (CREM) called EWSR1:CREM fusion, which confirmed the diagnosis. The overlap of the pathological features of IMMTs and angiomatoid fibrous histiocytomas may support the recent theory that these tumors are two manifestations of a single entity. Moreover, our study indicated the broad spectrum of immunohistochemical phenotypes of these tumors, which should be noted during diagnosis. Further studies are needed to elucidate the histopathological concept, long-term prognosis, optimal treatment strategy, and factors associated with the prognosis and therapeutic options of this condition.

Opposing Responses of the Calcium Channel Blocker Nicardipine to Vascular Stiffness in the Elastic and Muscular Arteries in Rabbits.

AIM: The cardio-ankle vascular index (CAVI) consists of intrinsic and functional arterial stiffness mainly regulated by vasoactive compounds. A new stiffness index of the aorta (aBeta) and iliac-femoral arteries (ifBeta) was determined by applying the CAVI theory to the whole aorta and iliac-femoral arteries. We investigated the changes in aBeta and ifBeta in response to decreased blood pressure (BP) induced by the Ca2＋ channel blocker nicardipine to elucidate the involvement of Ca2＋ in aBeta and ifBeta. METHODS: Pressure waves at the origin of the aorta (oA), distal end of the abdominal aorta (dA), and left femoral artery (fA) as well as flow waves at the oA were simultaneously recorded before and after the infusion of nicardipine (50 µg/kg/min) for 2 min in 12 male rabbits under pentobarbital anesthesia. Beta was calculated using the following formula: Beta=2ρ / PP×ln (SBP / DBP)×PWV2, where ρ, SBP, DBP, and PP denote blood density and systolic, diastolic, and pulse pressures, respectively. aBeta, ifBeta, and aortic-iliac-femoral Beta (aifBeta) were calculated using aPWV, ifPWV, and aifPWV, respectively. RESULTS: SBP, mean arterial pressure (MAP), DBP, and total peripheral vascular resistance significantly decreased during the administration of nicardipine, whereas cardiac output significantly increased. aBeta and ifBeta significantly increased and decreased, respectively, whereas aifBeta did not change despite the decrease in BP. ifBeta and aBeta positively and negatively correlated with BP, respectively, whereas aifBeta did not correlate with SBP. CONCLUSIONS: There were contradictory arterial responses to nicardipine between the elastic and muscular arteries. Unknown vasoconstriction mechanisms that are not involved in Ca2＋ influx may function in the aorta in response to decreased BP.

Cranial Tributary Ablation of the Saphenofemoral Junction during Laser Crossectomy of the Great Saphenous Vein.

Objectives: Anterior accessory saphenous vein (AASV) insufficiency is one of the most common causes of recurrent varicose veins after endovenous thermal ablation (EVTA) for great saphenous vein (GSV) insufficiency. The purpose of this study was to evaluate the efficacy and safety of cranial tributary ablation (CTA) during laser crossectomy (LC) of the GSV. Methods: We reviewed 182 limbs in 171 patients undergoing EVTA aiming for LC with a 1470-nm diode laser. In the CTA group, either the superficial circumflex iliac vein or the superficial epigastric vein was directly ablated during LC. The result was compared between the CTA (n=63) and control (n=119) groups using follow-up duplex ultrasound performed for 6 months after EVTA. Results: Initial success rate of CTA was 69%. The AASV occlusion rate (90% vs. 63%, p<0.001) and the flush GSV occlusion rate (68% vs. 30%, p<0.001) at 6 months were better in the CTA group. No major adverse events were observed. Conclusion: CTA during LC of the GSV is a safe and effective approach to achieve better flush or AASV occlusion rates after EVTA. It is occasionally technically demanding but can be a feasible option. Further investigation is needed to confirm our results.

Different Responses of Arterial Stiffness between the Aorta and the Iliofemoral Artery during the Administration of Phentolamine and Atenolol in Rabbits.

AIM: The mechanism underlying the stiffness of the aorta and iliofemoral artery that is required to maintain blood pressure (BP) is unclear. A new stiffness index of the aorta (aBeta) and iliac-femoral arteries (ifBeta) was defined by applying the cardio-ankle vascular index (CAVI). We compared changes in stiffness of the two arteries in response to reduced BP, due to the non-selective α adrenergic blocker phentolamine and the ß1 adrenergic blocker atenolol, in rabbits. METHODS: Pressure waves at the origin (oA) and distal ends of the aorta (dA) and the distal end of the left femoral artery (fA) were recorded simultaneously using three pressure sensors in 25 anesthetized rabbits. Phentolamine (50 µg/kg/min) and atenolol (10 mg/kg/min) were infused for 2 min. The pulse wave velocity (PWV) in each artery was determined; aBeta, ifBeta, and whole Beta (aifBeta) were calculated by the following formula; Beta=2ρ/PP×ln(SBP/DBP)×PWV2 (ρ: blood density; SBP, SBP, and PP: systolic, diastolic, and pulse pressures, respectively). RESULTS: SBP and DBP at oA, dA, and fA decreased by the administration of phentolamine and atenolol, with and without decreased total peripheral vascular resistance. After phentramine infusion, cardiac output (CO), aBeta, and aifBeta increased, while ifBeta decreased. After infusion of atenolol, CO decreased, while aBeta, ifBeta, and aifBeta remained unchanged. CONCLUSION: The contradictory reactions of aBeta and ifBeta to phentolamine suggest that the stiffness of the aorta and ilio-femoral artery is regulated separately during decreased BP induced by phentolamine, but not by atenolol.

Spaceflight affects postnatal development of the aortic wall in rats.

We investigated effect of microgravity environment during spaceflight on postnatal development of the rheological properties of the aorta in rats. The neonate rats were randomly divided at 7 days of age into the spaceflight, asynchronous ground control, and vivarium control groups (8 pups for one dam). The spaceflight group rats at 9 days of age were exposed to microgravity environment for 16 days. A longitudinal wall strip of the proximal descending thoracic aorta was subjected to stress-strain and stress-relaxation tests. Wall tensile force was significantly smaller in the spaceflight group than in the two control groups, whereas there were no significant differences in wall stress or incremental elastic modulus at each strain among the three groups. Wall thickness and number of smooth muscle fibers were significantly smaller in the spaceflight group than in the two control groups, but there were no significant differences in amounts of either the elastin or collagen fibers among the three groups. The decreased thickness was mainly caused by the decreased number of smooth muscle cells. Plastic deformation was observed only in the spaceflight group in the stress-strain test. A microgravity environment during spaceflight could affect postnatal development of the morphological and rheological properties of the aorta.

[Bridge to recovery with ventricular assist device support for eosinophilic myocarditis].

A 39-year-old man initially presented with cough, fever, and shortness of breath. His symptom got worse gradually, and he was admitted to a nearby hospital. Echocardiography revealed a dilated left ventricle and severe left ventricular dysfunction. Despite inotropic and intra-aortic balloon pumping (IABP) support, the patient developed cardiogenic shock with fever of unknown origin, followed by multi-organ failure. A left-ventricular assist device (LVAD) was implanted. Pathologic evaluation showed an extensive eosinophil-rich inflammatory infiltrate, and consistent with the diagnosis of eosinophilic myocarditis. After high-dose steroid administration, the cardiac function improved and explantation of the LVAD was successfully performed. The patient was discharged and remains well at the 24-month follow-up.

Effect of external counterpulsation on cardiac work following cardiac surgery: implications of the mechanism responsible for clinical benefits.

BACKGROUND: External counterpulsation (ECP) has been recognized as a non-invasive treatment for chronic refractory angina or heart failure. However, the mechanisms responsible for the clinical benefits of ECP therapy remain elusive. Moreover, the clinical significance of ECP therapy for postoperative patients has not been established yet. METHODS: Six adult patients received ECP therapy for 60 min under pulmonary artery catheter monitoring after cardiac surgery. Hemodynamic data were obtained before ECP therapy (pre-ECP), 20 min after ECP was commenced (20-min-ECP), 40 min after ECP was commenced (40-min-ECP), and after ECP therapy (post-ECP). RESULTS: The mean right atrial pressure (pre-ECP: 9 ± 4 mmHg; 20-min-ECP: 12 ± 5 mmHg; 40-min-ECP: 12 ± 4 mmHg; and post-ECP: 9 ± 4 mmHg), pulmonary wedge pressure (16 ± 6 mmHg, 20 ± 7 mmHg, 20 ± 7 mmHg, and 17 ± 7 mmHg, respectively), cardiac index (2.4 ± 0.4 l/min/m(2), 2.8 ± 0.6 l/min/m(2), 2.7 ± 0.5 l/min/m(2), and 2.5 ± 0.4 l/min/m(2), respectively), cardiac work index (2.5 ± 0.4 kgm/m(2), 3.3 ± 0.8 kgm/m(2), 3.1 ± 0.8 kgm/m(2), and 2.6 ± 0.5 kgm/m(2), respectively), and left ventricular stroke work index (32 ± 7 gm/m(2), 41 ± 12 gm/m(2), 39 ± 12 gm/m(2), and 33 ± 8 gm/m(2), respectively) significantly (p<0.05) increased after ECP was commenced (pre-ECP vs. 20-min-ECP) and decreased after ECP was discontinued (40-min-ECP vs. post-ECP). Significant (p<0.001) diastolic augmentation (20-min-ECP: 24 ± 6%, 40-min-ECP: 23 ± 5%) and systolic unloading (3 ± 1%, and 3 ± 1%, respectively) were obtained. No clinical adverse effects were observed. CONCLUSIONS: ECP increases venous return, cardiac output, and cardiac work in addition to diastolic augmentation and systolic unloading. These actions may play important roles in the clinical benefits of ECP therapy. Our data also suggest that ECP is beneficial for patients undergoing cardiac surgery.

Design of external forces for eliminating traveling wave in a piecewise linear FitzHugh-Nagumo model.

Elimination and control of nonlinear phenomena in excitable media are important for academic interests and practical applications. This paper provides a systematic procedure to design external forces for eliminating a traveling wave in a one-dimensional piecewise linear FitzHugh-Nagumo model. This procedure allows us to design nonfeedback and feedback control systems. The feedback control systems are designed using classical control theory. Furthermore, this procedure is extended to a two-dimensional model and verified using numerical simulation.

Experience of a patient with an extracorporeal ventricular assist system who participated in a sleepover program.

A 19-year-old woman suffered fulminant myocarditis owing to a mycoplasma infection and was inserted with an intra-aortic balloon pump and a percutaneous cardiopulmonary support. Antibiotics and gamma globulin were administered, however, the patient's cardiac function did not recover, and the TOYOBO ventricular assist device (VAD) was implanted. She had rehabilitation training such as maintaining a standing position at the bedside and walking in the hospital, and a hospital outing program to a family restaurant was conducted two times with the VAD. The patient wished to attend the coming-of-age ceremony in Tachikawa city, which is 3 h away from our hospital by car. Therefore, we planned the program including a night stay at her home. The patient and her family fully understood the risks and wished to participate in the sleepover program. In preparing for the sleepover, the patient and her family learned to operate the VAD, and she was able to move to the lavatory and through the house with the help of only her family. A physician and a clinical engineer stayed at her house for infusion of antibiotics and management of sudden changes. There was no adverse event. In Japan, the community support of patients with VAD is not yet established, and we hope that our experience becomes a help to support return to society for patients with VAD.

[The survey on the work environment of young cardiovascular surgeons].

We carried out the questionnaire of the working environment of young cardiovascular trainees, which are equal and less than ten years after graduation from medical school. We asked 261 surgeons for questionnaire on direct mail and 76 (29.1%) replied. Most of them thought they were working in poor environment. 47 surgeons (61.3%) were not satisfied with their current works. Main reasons were less chance of surgical cases as primary surgeons and lots of duties and paper works which were not related to operations and pre-and post-operative management. Primary thing that we have to do, would be to construct the system, which the medical clerk and physician's assistant share duties and reduce the labor burden on doctors. Many young surgeons expect to built up their social status as cardiovascular specialist. We considered that the improvement of working circumstances with establishing a system of physician assistant, drastic practice curriculums, would be necessary, before the discussion to put together cardiovascular institutions.

[Support for temporary homecoming of a patient with ventricular assist device].

A 19-year-old woman suffered from fulminant myocarditis by Mycoplasma infection, and intra-aortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) were initiated. As the cardiac function was not recovered, the ventricular assist device (VAS) was implanted. Rehabilitation training was started such as maintaining standing position at the bedside, and walking. The preparatory training program for homecoming was conducted twice with VAS. She strongly hoped for participation of coming-of-age ceremony in Tachikawa City that is 3 hours' drive from our hospital. The patient stayed 1 night at home with a doctor and a medical engineer. There was no adverse event. In Japan, the community support of patients with VAS is not yet established and we hope that our experience will be of some help in supporting the homecoming of patients with VAS.

A novel external counterpulsation system for coronary artery disease and heart failure: pilot studies and initial clinical experiences.

External counterpulsation (ECP) is a beneficial and noninvasive treatment for coronary artery disease or heart failure; however, it still has a lot of limitations. We used a novel ECP system, Compact CP, the main feature of which is the double-lumen cuff that reduces the impact of cuff inflation and the size of the air compressor. The first lumen was a contact cuff that was attached to the legs with a constant pressure (8 kPa). The second lumen was a main cuff that was inflated and deflated with a driving pressure and synchronized to the cardiac cycle. In this report, we describe the results of four pilot studies in a total number of 39 healthy volunteers and initial clinical experiences of this system in three patients. The pilot studies demonstrated that the ECP system provided significant diastolic augmentation and systolic unloading. It also achieved a satisfactory diastolic/systolic pressure ratio (1.00 ± 0.06) with a high comfort level at a driving pressure of 40 kPa. Higher pressure (50-70 kPa) increased the assist performance but decreased the comfort level. ECP was also applied with a patient with chronic refractory angina and two patients with postoperative heart failure following cardiac surgery. The clinical conditions improved. No adverse effect was observed. Our novel ECP system is safe, effective, and promising in the treatment of coronary artery disease or heart failure. Further clinical investigations are needed to support the significance of this system.

Adventitial cystic disease of the femoral vein.

Adventitial cystic disease of the blood vessel wall is a rare disease. It occurs most commonly in arteries and very rarely in veins (Levien and Benn, J. Vasc. Surg. 1998;28:193-205). We report the case of a 28-year-old man with severe adventitial cystic disease of the femoral vein who underwent a resection of the cystic wall.

Mid-term results and costs of coronary artery bypass vs drug-eluting stents for unprotected left main coronary artery disease.

BACKGROUND: The optimal revascularization strategy for unprotected left main coronary artery (ULMCA) disease in the era of drug-eluting stents (DES) has become more controversial between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). METHODS AND RESULTS: Since April 2004, 89 patients underwent CABG, including 82 (92.1%) off-pump procedures and 63 patients underwent PCI with DES for ULMCA disease. Major adverse cardiac and cerebrovascular events (MACCE: death, acute myocardial infarction, stroke and repeat revascularization) and hospitalization costs were compared. Patients in the CABG group were likely to have multivessel disease and higher euroSCORE. The mean follow-up was 2.2+/-1.1 years in the CABG group and 1.6+/-0.8 years in the DES group (P<0.001). The overall survival rate did not differ (P=0.288) between the groups (CABG: 93.4% and DES: 91.9% at 2 years). The MACCE-free survival rate was better (P=0.033) in the CABG group (CABG: 82.2% and DES: 62.6% at 2 years). Total hospitalization costs were lower (P=0.013) in the CABG group (median: 3,225 thousand yen) than in the DES group (median: 4,192 thousand yen). CONCLUSIONS: CABG might be associated with cost-effectiveness and could be still the first revascularization strategy for ULMCA disease.

Cardiovascular regulation during upright standing behavior in conscious rats.

Although rats often show an upright standing behavior the cardiovascular response during the behavior has not yet been fully clarified. In this study we quantified the activity of upright standing behavior in rats using infrared beam detectors and measured cardiovascular variables during the behavior. Rats demonstrated a high level of upright standing activity as they showed the upright posture more than 500 times per day at 10 weeks of age. The average upright standing duration time was less than 10s. Arterial pressure slightly decreased while heart rate increased in response to the behavior and these responses were not affected by sino-aortic denervation. Our results indicate that other mechanisms such as the vestibulo-cardiovascular reflex may completely compensate the lack of the baroreceptor reflex to maintain cardiovascular homeostasis in response to acute positional changes in rats. Moreover rats demonstrate complex integrative mechanisms maintaining cardiovascular homeostasis against the upright standing behavior which frequently occurs in rats.